NAMCP Medical Directors Institute
Associate Membership Application

   

We encourage you to complete your online registration at this time.  Our site is protected by VeriSign, the industry leader in encryption.
Name:
Date:
Title:
Organization:
Address:
City:
State:
Zip Code:
Work Phone:
Fax:
Cell Phone:
Email:
How many years have you
served in your current role?:

 

Credentials:

MD  RN    PhD  MS       MPA
RPh MBA MPH PharmD Other

Which of the following best
describes your employer?:

Pharmaceutical Manufacturer
Medical Device Company
Retail Pharmacy
Consulting Firm
Association
 

PBM
Disease Management Company
Biotech
Speciality Pharmacy
Other (specify)


 

 Please Choose One That
Best Describes Your Job Function:

Reimbursement Director
Professional Relations
Director, Managed Care
Associate Director
Other:



 
Director
Account Manager
Marketing/Sales
Principal
Consultant

 

Fee  

Annual dues in the amount of $195.00
When you click submit you will be sent to the next page for payment by credit card.
 

Payment 

   
If Paying by Check, Check #:
When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction.
 
 If Paying by Credit Card:   When you hit submit you will be sent to the page for payment by credit card.
If you are paying by credit card and the cardholder name is different than applicant name above, please enter cardholder name here:
 
 

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Remittance of dues must accompany this application. Make checks
payable to NAMCP and mail to 4435 Waterfront Drive, Suite 101,
Glen Allen, Virginia 23060. For more information please call 804-527-1905.
When paying by credit card, application may be faxed to 804-747-5316.
(Tax ID#
54-1566359). The NAMCP is a non-for-profit 501(c)6 organization.

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Copyright 2011 NAMCP. All rights reserved.
Revised: January 05, 2016.